• Assess type, location, and intensity of pain before and 24 hr after application and periodically during therapy. Monitor pain frequently during initiation of therapy and dose changes to assess need for supplementary analgesics for breakthrough pain.
• Assess BP, pulse, and respirations before and periodically during administration. If respiratory rate <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Dose may need to be ↓ by 25–50%. Initial drowsiness will diminish with continued use. Monitor for respiratory depression, especially during initiation or following dose increase; serious, life-threatening, or fatal respiratory depression may occur. May cause sleep-related breathing disorders (central sleep apnea, sleep-related hypoxemia).
• Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive opioid analgesics for pain rarely develop psychological dependence.
• Assess for opioid-induced hyperalgesia, which can appear as ↑ levels of pain upon increasing the dose of the opioid, ↓ levels of pain upon decreasing the dose of the opioid, or pain from ordinarily nonpainful stimuli (allodynia). This condition is different from tolerance. If a patient is suspected to be experiencing opioid-induced hyperalgesia, consider ↓ the dose of the current opioid or switching to a different opioid analgesic.
• Progressively higher doses may be required to relieve pain with long-term therapy. It may take up to 6 days after ↑ doses to reach equilibrium, so patients should wear higher dose through two applications before ↑ dose again. ↑ doses and prolonged use may ↑ risk of overdose. Prolonged use of opioids should be reserved for patients whose pain remains severe enough to require them and alternative treatment options continue to be inadequate. Many acute pain conditions treated in the outpatient setting require no more than a few days of an opioid pain medicine.
• Assess bowel function routinely. Prevent constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2–3 days, unless contraindicated. Consider drugs for opioid-induced constipation.
• Assess risk for opioid addiction, abuse, or misuse prior to administration. Misuse or abuse of transdermal fentanyl by chewing, swallowing, snorting, or injecting fentanyl extracted from transdermal system will result in the uncontrolled delivery of fentanyl and risk of overdose and death.

Lab Test Considerations:

• May ↑ plasma amylase and lipase levels.

Toxicity and Overdose:

• If an opioid antagonist is required to reverse respiratory depression or coma, naloxone is the antidote. Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by IV push every 2 min. For patients weighing <40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain. Monitor patient closely; dose may need to be repeated or may need to be administered as an infusion because of long duration of action despite removal of patch.